Case Studies

A painful foot problem was interfering with this 64-year-old male retiree’s ability to get around and engage in activities of daily living, which included work as a community volunteer. He came to us on a referral from his family doctor.

Clinical evaluation of the patient revealed pain over the inside of his ankle and swelling along the tendon there. Observed was a pronounced valgus heel deformity. X-rays of the collapsed and outwardly turned inner foot were taken under weight-bearing conditions. These demonstrated a subluxated talonavicular joint. An MRI was then produced to define the pathology of that out-of-position joint.

The MRI revealed posterior tibial tendon deterioration and a torn calcaneonavicular ligament.

Initially, we fitted the patient for an AFO articulated ankle brace. Substantial relief from the pain was achieved, but after two months of use, the patient decided wearing the brace indefinitely would be impractical. His only viable alternative to the brace was a medial calcaneal osteotomy. The 90-minute surgery began by taking a lateral approach through the superficial fascia and periosteum, then cutting through the medial side of the calcaneus. The calcaneus cut was made at an oblique angle and we slid it into its new position – roughly 1cm medially. Fixation was achieved by means of a single 50mm Acutrak screw placed across the osteotomy.

The second phase of the surgery involved repair of the torn calcaneonavicular ligament and posterior tibial tendon. This was accomplished by removing the damaged portion and reinforcing the tendon with the nearby flexor digitorum longus by weaving it through the navicular bone. A pain pump was placed near the sciatic nerve by the anesthesiologist to decrease postoperataive pain.

The patient remained in the outpatient surgery center overnight. He was seen again by us 48 hours later to have the pain pump removed, check the wound and have a cast placed. Oral narcotic pain medications were prescribed, which the patient continued for two weeks. At the end of those two weeks, the cast and stitches were removed and he was fitted for a cast boot. Two weeks later, we began his physical therapy.

At six weeks postoperatively, the patient was able to ambulate unassisted. At ten weeks postoperatively, he began wearing tennis shoes with arch supports. Today, the patient is pain-free and has regained full and normal use of his foot.

Calcaneal osteotomies have long been a part of our armamentarium of foot-and-ankle surgical procedures. We believe they are invaluable for correcting significant valgus as well as varus deformities. The procedure works its therapeutic wonders by realigning the position of the heel at the time of heel strike. In this particular case, we used the sliding-type calcaneal osteotomy to center the valgus heel back under the leg to lessen the strain on his  damaged tendon. Sliding calcaneal osteotomies also are scientifically proven effective in the treatment of adult tibialis posterior dysfunction. And it frequently is paired with medial procedures such as tendon repair, FDL transfer,

Cotton osteotomy and limited medial column fusions. Advantages are technical simplicity and high a rate of  healing.